Basic Information
Provider Information | |||||||||
NPI: | 1922587690 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAPTIST HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAPTIST HEALTH FOOT AND ANKLE CLINIC-FORT SMITH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11001 EXECUTIVE CENTER DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722114393 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5018127215 | ||||||||
FaxNumber: | 5018127207 | ||||||||
Practice Location | |||||||||
Address1: | 1500 DODSON AVE STE 260 | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 72901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4795737905 | ||||||||
FaxNumber: | 4795737906 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2018 | ||||||||
LastUpdateDate: | 10/15/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUSHER | ||||||||
AuthorizedOfficialFirstName: | WILL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5018127800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.